In August this year, a 20-year-old woman took herself to the A&E department at Lewisham University Hospital in South London. She had developed sepsis, a life-threatening blood infection, after giving birth to her baby a week earlier, and required urgent medical care.
Holding her baby in her arms and despite crying in fear, Abi Lewis*, a senior midwife at the hospital, recalls how staff at A&E sent her home on the bus to drop off her baby, even though the labour ward was advising otherwise. “After she didn’t come up to the ward, I called down to A&E to check where she was. The second I heard about the way she was being treated, I knew she was black. I’ve seen this kind of treatment towards black women many times, where their illness is not taken seriously,” she says. “I love the NHS, and am proud that we are able to provide free treatment to millions of people. But I have no doubt that the NHS is unintentionally but inherently systemically racist.”
The incident is by no means isolated. It is indisputable that the black community is more at risk in the medical system than their white counterparts due to both medical ignorance and unconscious bias. Take childbirth. In the UK alone, black women are five times more likely to die in childbirth than white women. In the first month of the pandemic, Black, Asian and minority ethnic (BAME) people accounted for 72% of NHS staff and carer deaths from Covid-19, yet they only make up 44% of staff. “Black people do not have a genetic propensity to die,” says Dr Nagla Elfaki, a doctor in obstetrics and gynaecology at Barking, Havering and Redbridge University Hospitals NHS Trust. “But the consequences of systemic oppression and institutionalised racism, including poverty, poor housing and poor health literacy, combined with inherent biases within medicine have a cumulative and devastating effect on health outcomes.”
Abi has experienced this unconscious bias first hand on many occasions. “Last year, I had a patient who was admitted with a non-viable pregnancy [the baby would not survive],” recalls Abi. “She had quite severe diabetes, which needed management, but no one was treating her, despite her asking for help. I remember urging one of the consultants to see to her condition, and he shrugged and said ‘yeah but the baby won’t make it’. What about the mother? Wasn’t she worth saving, too?”
Much of this ingrained bias within medicine can be traced back to slavery, when physicians would claim that black slaves could endure more pain than white people in order to facilitate further enslavement and torture. Slaves were often operated on for medical research purposes without anaesthetic and during World War II, these stereotypes justified the US military’s decision to test chemical weapons on black soldiers and even today, they still prevail. “Until 1970s, they were still printing medical textbooks that said black people have a higher pain threshold,” says Dr Elfaki. “This translates into racial bias within pain management and general treatment of black patients.”
There are more nuanced problems with the current medical syllabus, too. Mainly, that it is geared towards the treatment of white patients. “At university, the prototype in our anatomy textbooks was a white male,” says Dr Tosin Sotubo, GP and founder of Mind Body Doctor. “You’re not learning how to treat all people, you’re mainly learning how to treat white men.” Obvious problems occur as a result, namely that doctors are ill-equipped to treat black and ethnic minority people.
Take rashes as an example; rashes present differently on different skin colours. Only learning what they look like on white skin leaves doctors unable to recognise and diagnose potentially life-threatening illnesses like meningitis, measles and Lyme disease, on non-white patients as a result. “A more extreme example is Kawasaki’s disease, which although rare is the most common cause of heart disease in children” explains Dr Ifeoma Ejikeme, dermatologist. “The rash looks totally different on black skin and with incorrect training could easily be dismissed for a simple viral rash, with dire consequences.”
This white-centric approach was also shown as recently as the Covid-19 pandemic. “The general messaging was to call 999 if a person looked pale or if their lips turned blue, as this would be a sign they weren’t breathing properly. Black people don’t go pale, or turn blue,” says Dr Elfaki. “Patients have become aware that doctors don’t understand or recognise their illness or their pain because of the way that they look, and there’s a huge amount of distrust from black and ethnic minority patients towards the NHS as a result.”
As well as decolonising the curriculum and removing racial bias from medical training, important changes need to be made in terms of representation at a board level. “In London, almost half of NHS employees are black and ethnic minority, but 92% of NHS Trust Board members are white,” notes Dr Elfaki.
It has been over ten years since the Department Of Health announced that they must “give even greater prominence to race equality”, with a “systematic action plan” to increase representation at the top tiers of the service to 30 per cent BME. It’s clear they have failed in this objective spectacularly. A study by Roger Kline at Middlesex University in 2014 titled “The Snowy White Peaks of the NHS” found that there had been no significant change in the proportion of BAME Trust Board appointments in recent years, “continuing the pattern of under-representation compared to both the workforce and the local population.”
It also found that BAME staff were twice as likely to enter the disciplinary process and BAME nurses take 50% longer to be promoted compared to white nurses. “You may see a lot of black and brown faces at the bottom, but you can’t let it lull you into a false sense of security because these people aren’t in positions where they can make changes or influence the system,” says Dr Elfaki. In response, the NHS Workforce Race Equality Standard was set up in 2015, which is a live initiative that aims to implement a strategic approach to improve BAME representation at senior management and Board level and to help to provide a better working environment for the BAME workforce.
For Abi, however, racism is still a reality of her everyday workplace – not just from patients, but from colleagues, too: “When the protests were taking place after the killing of George Floyd, a senior member of medical staff was leaving comments on Facebook that were anti-Black Lives Matter.” The comments included, “Can we just not have our street names changed to Mugabe Ave or Zambia Way. Thanks!” on a politician’s public page. “A number of us complained, but we were told there was nothing that could be done,” says Abi.
After months of much-deserved national appreciation for the NHS, it seems obvious that the system also has deep rooted problems that will need more than clapping to solve. “The clapping was a nice gesture,” says Dr Elfaki. “But we need to go beyond gestures. We need tangible and financial resources to incur lasting and meaningful change.”
GLAMOUR contacted Lewisham And Greenwich NHS Trust for comments to which a spokesperson said: “We do not tolerate any form of racism in the workplace, and all complaints we receive are thoroughly investigated.” Regarding the incidence of the patient with diabetes, a spokesperson for the Trust commented: “We would urge colleagues to raise concerns about these allegations internally, so that we can carry out a full investigation and take appropriate action. We have a code of conduct for all our staff to ensure that patients and colleagues are treated with respect and compassion at all times. We support and encourage all colleagues to raise concerns with us, and recently introduced an independent speaking up service to provide confidential advice and support. We also publish the results of employee relations investigations internally to show that poor behaviour is not tolerated in the Trust.”
*Names and details have been changed to protect identities.